Healthcare Provider Details

I. General information

NPI: 1447176011
Provider Name (Legal Business Name): JENNIFER CONNELLY CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3540 MORRISON AVE
BERKLEY MI
48072-1459
US

IV. Provider business mailing address

3540 MORRISON AVE
BERKLEY MI
48072-1459
US

V. Phone/Fax

Practice location:
  • Phone: 248-837-8756
  • Fax:
Mailing address:
  • Phone: 734-755-6272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101000403
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: